Abstract Background Out-of-hospital cardiac arrest (OHCA) remains a leading cause of death and a 2010 meta-analysis concluded that outcomes have not improved over several decades. However, guidelines ...have changed to emphasize CPR quality, minimization of interruptions, and standardized post-resuscitation care. We sought to evaluate whether OHCA outcomes have improved over time among agencies participating in the Resuscitation Outcomes Consortium (ROC) cardiac arrest registry (Epistry) and randomized clinical trials (RCTs). Methods Observational cohort study of 47,148 EMS-treated OHCA cases in Epistry from 139 EMS agencies at 10 ROC sites that participated in at least one RCT between 1/1/2006 and 12/31/2010. We reviewed patient, scene, event characteristics, and outcomes of EMS-treated OHCA over time, including subgroups with initial rhythm of pulseless ventricular tachycardia or ventricular fibrillation (VT/VF). Results Mean response interval, median age and male proportion remained similar over time. Unadjusted survival to discharge increased between 2006 and 2010 for treated OHCA (from 8.2% to 10.4%), as well as for subgroups of VT/VF (21.4% to 29.3%) and bystander witnessed VT/VF (23.5% to 30.3%). Compared with 2006, adjusted survival to discharge was significantly higher in 2010 for treated cases (OR = 1.72; 95% CI 1.53, 1.94), VT/VF cases (OR = 1.69; 95% CI 1.45, 1.98) and bystander witnessed VT/VF cases (OR = 1.65; 95% CI 1.36, 2.00). Tests for trend in each subgroup were significant ( p < 0.001). Conclusions ROC-wide survival increased significantly between 2006 and 2010. Additional research efforts are warranted to identify specific factors associated with this improvement.
OBJECTIVE:Guidelines for cardiopulmonary resuscitation recommend a chest compression rate of at least 100 compressions/min. A recent clinical study reported optimal return of spontaneous circulation ...with rates between 100 and 120/min during cardiopulmonary resuscitation for out-of-hospital cardiac arrest. However, the relationship between compression rate and survival is still undetermined.
DESIGN:Prospective, observational study.
SETTING:Data is from the Resuscitation Outcomes Consortium Prehospital Resuscitation IMpedance threshold device and Early versus Delayed analysis clinical trial.
PARTICIPANTS:Adults with out-of-hospital cardiac arrest treated by emergency medical service providers.
INTERVENTIONS:None.
MEASUREMENTS MAIN RESULTS:Data were abstracted from monitor-defibrillator recordings for the first five minutes of emergency medical service cardiopulmonary resuscitation. Multiple logistic regression assessed odds ratio for survival by compression rate categories (<80, 80–99, 100–119, 120–139, ≥140), both unadjusted and adjusted for sex, age, witnessed status, attempted bystander cardiopulmonary resuscitation, location of arrest, chest compression fraction and depth, first rhythm, and study site. Compression rate data were available for 10,371 patients; 6,399 also had chest compression fraction and depth data. Age (mean ± SD) was 67 ± 16 years. Chest compression rate was 111 ± 19 per minute, compression fraction was 0.70 ± 0.17, and compression depth was 42 ± 12 mm. Circulation was restored in 34%; 9% survived to hospital discharge. After adjustment for covariates without chest compression depth and fraction (n = 10,371), a global test found no significant relationship between compression rate and survival (p = 0.19). However, after adjustment for covariates including chest compression depth and fraction (n = 6,399), the global test found a significant relationship between compression rate and survival (p = 0.02), with the reference group (100–119 compressions/min) having the greatest likelihood for survival.
CONCLUSIONS:After adjustment for chest compression fraction and depth, compression rates between 100 and 120 per minute were associated with greatest survival to hospital discharge.
BACKGROUND:Antiarrhythmic drugs have not proven to significantly improve overall survival after out-of-hospital cardiac arrest from shock-refractory ventricular fibrillation/pulseless ventricular ...tachycardia. How this might be influenced by the route of drug administration is not known.
METHODS:In this prespecified analysis of a randomized, placebo-controlled clinical trial, we compared the differences in survival to hospital discharge in adults with shock-refractory ventricular fibrillation/pulseless ventricular tachycardia out-of-hospital cardiac arrest who were randomly assigned by emergency medical services personnel to an antiarrhythmic drug versus placebo in the ALPS trial (Resuscitation Outcomes Consortium Amiodarone, Lidocaine or Placebo Study), when stratified by the intravenous versus intraosseous route of administration.
RESULTS:Of 3019 randomly assigned patients with a known vascular access site, 2358 received ALPS drugs intravenously and 661 patients by the intraosseous route. Intraosseous and intravenous groups differed in sex, time-to-emergency medical services arrival, and some cardiopulmonary resuscitation characteristics, but were similar in others, including time-to-intravenous/intrasosseous drug receipt. Overall hospital discharge survival was 23%. In comparison with placebo, discharge survival was significantly higher in recipients of intravenous amiodarone (adjusted risk ratio, 1.26 95% CI, 1.06–1.50; adjusted absolute survival difference, 5.5% 95% CI, 1.5–9.5) and intravenous lidocaine (adjusted risk ratio, 1.21 95% CI, 1.02–1.45; adjusted absolute survival difference, 4.7% 95% CI, 0.7–8.8); but not in recipients of intraosseous amiodarone (adjusted risk ratio, 0.94 95% CI, 0.66–1.32) or intraosseous lidocaine (adjusted risk ratio, 1.03 95% CI, 0.74–1.44). Survival to hospital admission also increased significantly when drugs were given intravenously but not intraosseously, and favored improved neurological outcome at discharge. There were no outcome differences between intravenous and intraosseous placebo, indicating that the access route itself did not demarcate patients with poor prognosis. The study was underpowered to assess intravenous/intraosseous drug interactions, which were not statistically significant.
CONCLUSIONS:We found no significant effect modification by drug administration route for amiodarone or lidocaine in comparison with placebo during out-of-hospital cardiac arrest. However, point estimates for the effects of both drugs in comparison with placebo were significantly greater for the intravenous than for the intraosseous route across virtually all outcomes and beneficial only for the intravenous route. Given that the study was underpowered to statistically assess interactions, these findings signal the potential importance of the drug administration route during resuscitation that merits further investigation.
IMPORTANCE: Emergency medical services (EMS) commonly perform endotracheal intubation (ETI) or insertion of supraglottic airways, such as the laryngeal tube (LT), on patients with out-of-hospital ...cardiac arrest (OHCA). The optimal method for OHCA advanced airway management is unknown. OBJECTIVE: To compare the effectiveness of a strategy of initial LT insertion vs initial ETI in adults with OHCA. DESIGN, SETTING, AND PARTICIPANTS: Multicenter pragmatic cluster-crossover clinical trial involving EMS agencies from the Resuscitation Outcomes Consortium. The trial included 3004 adults with OHCA and anticipated need for advanced airway management who were enrolled from December 1, 2015, to November 4, 2017. The final date of follow-up was November 10, 2017. INTERVENTIONS: Twenty-seven EMS agencies were randomized in 13 clusters to initial airway management strategy with LT (n = 1505 patients) or ETI (n = 1499 patients), with crossover to the alternate strategy at 3- to 5-month intervals. MAIN OUTCOMES AND MEASURES: The primary outcome was 72-hour survival. Secondary outcomes included return of spontaneous circulation, survival to hospital discharge, favorable neurological status at hospital discharge (Modified Rankin Scale score ≤3), and key adverse events. RESULTS: Among 3004 enrolled patients (median interquartile range age, 64 53-76 years, 1829 60.9% men), 3000 were included in the primary analysis. Rates of initial airway success were 90.3% with LT and 51.6% with ETI. Seventy-two hour survival was 18.3% in the LT group vs 15.4% in the ETI group (adjusted difference, 2.9% 95% CI, 0.2%-5.6%; P = .04). Secondary outcomes in the LT group vs ETI group were return of spontaneous circulation (27.9% vs 24.3%; adjusted difference, 3.6% 95% CI, 0.3%-6.8%; P = .03); hospital survival (10.8% vs 8.1%; adjusted difference, 2.7% 95% CI, 0.6%-4.8%; P = .01); and favorable neurological status at discharge (7.1% vs 5.0%; adjusted difference, 2.1% 95% CI, 0.3%-3.8%; P = .02). There were no significant differences in oropharyngeal or hypopharyngeal injury (0.2% vs 0.3%), airway swelling (1.1% vs 1.0%), or pneumonia or pneumonitis (26.1% vs 22.3%). CONCLUSIONS AND RELEVANCE: Among adults with OHCA, a strategy of initial LT insertion was associated with significantly greater 72-hour survival compared with a strategy of initial ETI. These findings suggest that LT insertion may be considered as an initial airway management strategy in patients with OHCA, but limitations of the pragmatic design, practice setting, and ETI performance characteristics suggest that further research is warranted. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02419573
Out-of-hospital cardiac arrest (OHCA) has high incidence and mortality. The survival benefit of pre-hospital advanced airway management (AAM) for OHCA remains controversial. In Japan, pre-hospital ...AAM are performed for OHCA by emergency medical services (EMS), however the relationship between resuscitation outcomes and AAM at the prefecture level has not been evaluated. The purpose of this study was to describe the association between AAM and neurologically favorable survival (cerebral performance category (CPC) ≦2) at prefecture level. This was a retrospective, population-based study of adult OHCA patients (≧ 18) from January 1, 2014 to December 31, 2017 in Japan. We excluded patients with EMS witnessed arrests. We also only included patients that had care provided by an ELST with the ability to provided AAM and excluded cases that involved prehospital care delivered by a physician. We categorized OHCA into four quartiles (four group: G1-G4) based on frequency of pre-hospital AAM approach rate by prefecture, which is the smallest geographical classification unit, and evaluated the relationship between frequency of pre-hospital AAM approach rates and CPC ≦ 2 for each quartile. Multivariable logistic regression was used to assess effectiveness of AAM on neurologically favorable survival. Among 493,577 OHCA cases, 403,707 matched our inclusion criteria. The number of CPC ≦ 2 survivors increased from G1 to G4 (p for trend < 0.001). In the adjusted multivariable regression, higher frequency of pre-hospital AAM approach was associated with CPC ≦ 2 (p < 0.001). High prefecture frequency of pre-hospital AAM approach was associated with neurologically favorable survival (CPC ≦ 2) in OHCA.
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